Dr Geoff deals with the issue of cot death in this article that goes into more depth than his usual articles:
We are bombarded with advice about diet, lifestyle and health; much of it is based upon tenuous evidence and put forward in the mass media by people with no credible medical or scientific expertise. Health promotion that is not supported by convincing evidence of holistic benefit can be dangerous. If dietary and lifestyle changes have the potential to promote health then they must also have the potential to do harm.
Antioxidants are a good example of the effects of media frenzy. Several items a week appear in the media promoting the benefit of some supplement or food on the basis of its antioxidant content. This cumulative pressure has persuaded many people to take antioxidant supplements. Yet numerous clinical trials have yet to show that any antioxidant supplement has net holistic benefit. These trials provide no suggestion that supplements of the major antioxidants like vitamin E, vitamin C, β-carotene or co-enzyme Q10 have any benefits in reducing cancer or heart disease and even suggest that β-carotene supplements may increase heart disease and cancer risk (see Webb, 2006). A recent trial of high doses of antioxidant supplements for prevention of pre-eclampsia found that they caused a slightly earlier onset of pre-eclampsia (Poston et al, 2006).
The changing rate of cot death provides a dramatic and quantifiable example of the potential hazards of encouraging ill-founded behaviour change (Webb, 1995). Yet it is usually trumpeted as a major success story for health promotion and the fact that the cot death “epidemic” in the 1970s and 1980s was largely created by health promotion is hardly ever mentioned.
Front sleeping substantially increases the risk of a baby suffering cot death (DH, 1993). In recognition of this, the “Back to Sleep” campaign was started in the UK in 1991 and parents were advised to avoid the front sleeping position. As a result of this campaign, cot death rates were halved in 1992 compared to 1991 and in March 1993 the Health Secretary was quoted thus:
“These figures on cot deaths show that behaviour change can work, can save lives, in this case the lives of small babies but it could just as well be our own.”
An editorial in The Times of 30/3/93 suggested that these figures should:
“encourage the health secretary”……”in her drive to promote preventive medicine”
The cot death rate in Britain has continued to fall since 1992 and earlier this year (18/1/2006) the director of The Foundation for the Study of Infant Deaths was quoted as saying that 14,000 lives had been saved since the advice to reduce the risk of cot death was introduced in 1991.
In 1971, however, rates of cot death in the UK were not much different to the current low rates. Rates increased thereafter and peaked in 1986 at around 6 times the current rate (Anderson et al, 1995). Similar rises occurred in other industrialised countries around this time; Webb (1995) details changes in Holland.
Prior to 1970, use of the front sleeping position was very uncommon (<5%) in Britain and other industrialised countries (DH, 1993). It was only after advice from health professionals and baby care writers that the use of front sleeping became common. The advice to use the front sleeping position was based upon very flimsy evidence. Studies in special baby care units suggested that prone sleeping improves blood oxygenation in premature babies and other benefits such as reduced risk of choking on regurgitated milk were largely assumed (DH, 1993). In Holland in 1972 there was a high profile campaign to promote front sleeping (DH, 1993) – a “Front to Sleep” campaign in all but name. More diffuse campaigns occurred in other countries including Britain.
Webb (1995) surveyed baby care books published in the 1980s and found an almost unanimous recommendation of front sleeping including the Health Education Council’s Pregnancy Book up to 1991.
Much of the large rise in cot deaths in the 1970s and 1980s occurred because parents were persuaded by “the experts” to use the “safer” front sleeping position and so one must conclude that thousands of babies died as a result of this misguided but well-intentioned advice. The 14,000 lives saved since 1991 are largely extra deaths that have been prevented by withdrawal of the earlier incorrect advice on sleeping position.
Behaviour change can cost lives as well as save them
Like all front line health professionals, midwives are expected to give dietary and lifestyle advice. Those advising upon health have a duty to ensure that the advice they give comes from authoritative sources and is clearly evidence-based. Pregnancy and the neonatal period are probably the times of greatest vulnerability in the human lifecycle which makes this obligation even greater for midwives.
Anderson R, Britton J, Esmail A, Hollowell J and Strachan D (1995) Respiratory disease and Sudden Infant Death Syndrome. In: The Health of our children. Decennial supplement. Edited by Botting, B. HMSO, London: 113-134.
DH (1993) Report of the Chief Medical Officer’s Expert Group on the sleeping position of infants and cot death. HMSO, London.
Poston L, Briley AL, Seed PT et al (2006) Vitamin C and vitamin E in pregnant women at risk for pre-eclampsia (VIP trial): randomised placebo-controlled trial. Lancet, 367: 1145-1154.
Webb GP (1995) Sleeping position and cot death: does health promotion always promote health? Journal of Biological Education, 29: 279-85.
Webb GP (2006) Dietary supplements and functional foods. Blackwell, Oxford.
Dr Geoff will be covering a different topic in his next post but if you’re interested about in this issue please contact him directly or for more information please refer to his books which cover the issue in more detail